Ulcerative colitis

Background

Average inner diameters and ranges of different sections of the large intestine.

• Inflammation tends to be progressively more severe from proximal to distal colon
• Rectum is almost always involved
• Peak incidence occurs in second and third decades of life

Crohn's disease vs. ulcerative colitis

Crohn's disease vs. ulcerative colitis

Finding	Crohn's disease	Ulcerative colitis
Depth of inflammation	May be transmural, deep into tissues	Shallow, mucosal
Distribution of disease	Patchy areas of inflammation (skip lesions)	Continuous area of inflammation
Terminal ileum involvement	Commonly	Seldom
Colon involvement	Usually	Always
Rectum involvement	Seldom	Usually (95%)
Involvement around anus	Common	Seldom
Stenosis	Common	Seldom

Clinical Features

• Abdominal cramps and diarrhea (often bloody)

Classification

• Mild
  • <4 bowel movements per day
  • No systemic symptoms
  • Few extraintestinal manifestations
  • Occasional constipation and rectal bleeding
• Moderate
  • Colitis extends to splenic flexure
• Severe
  • Frequent BM
  • Anemia
  • Fever
  • Weight loss
  • Frequent extraintestinal manifestations
  • Pancolitis

Differential Diagnosis

Colitis

• Infectious colitis
• Ischemic colitis
• Ulcerative colitis
• CMV colitis
• Crohn's colitis
• Toxic colitis (antineoplastic agents)
• Pseudomembranous colitis
• Fibrosing colonopathy (Cystic fibrosis)

Evaluation

Work-up

• CBC
• Chemistry
• LFTs/lipase
• Consider:
  • ESR/CRP
  • Fecal calprotectin (typically requested by GI)
  • Type and screen (if significant bleeding)
• Imaging
  • Consider CT based on clinical features and need to rule out more concerning processes

Diagnosis

• Positive atypical p-ANCA and negative ASCA is specific for ulcerative colitis

Management

1. Rule-out complications:
   • Hemorrhage
   • Toxic megacolon
     • Develops in advanced disease when all the layers of the colon become involved
     • Presentation
       • Severely ill
       • Abdomen distended, tender, peritonitis
       • Fever, tachycardia
       • Leukocytosis (may be masked if patient taking steroids)
     • Perforation results in high mortality
     • Abdominal x-ray: long, continuous segment of air-filled colon >6cm in diameter
   • Perirectal fistula
   • Perirectal abscess
   • Obstruction (due to stricture)
   • Carcinoma
2. Steroids
   • Parenteral vs PO depending on severity
     • PO: prednisone 40mg x 2wks, then decrease by 5mg per week

Medication Dosing

Prednisone 40mg daily x 2 weeks, then taper by 5mg/week PO

Disposition

• Admit for severe complication or severe flare requiring IV steroids

See Also

• Colitis